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COMPARISON OF FRENULOTOMY VERSUS FRENULECTOMY IN CASES OF

ANKYLOGLOSSIA

Article  in  Journal of Postgraduate Medical Institute · July 2018

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 ORIGINAL ARTICLE

COMPARISON OF FRENULOTOMY VERSUS FRENULECTOMY IN

CASES OF ANKYLOGLOSSIA
Muhammad Ahmed Khan¹, Sumera Akram², Hassan Bin Usman³, Ghazanfar Ali⁴

1-4
Combined Military Hospi-
tal, Bahawalpur Cantonment,
Bahawalpur – Pakistan.
Address for Correspondence:
Dr. Muhammad Ahmed Khan
Combined Military Hospital,
Bahawalpur Cantonment, Ba-
hawalpur – Pakistan.
Email: akawan79@gmail.com
Date Received: April 01, 2017
Date Revised: May 06, 2018
Date Accepted: May 13, 2018
ABSTRACT
Objective: To compare frenulotomy versus frenulectomy in cases of ankylo-
glossia in terms of post operative improvement in speech and feeding difficul-
ties in children.
Methodology: This study was carried out in Combined Military Hospital (CMH),
Bahawalpur. Total 64 cases of tongue tie were selected from outpatient depart-
ment. The cases were randomly divided into two groups. In group A, children
underwent frenulectomy via Z-plasty and in group B they had frenulotomy i.e.
release of tongue tie with bipolar diathermy. Postoperative improvement in
speech and feeding problems was assessed in both groups.
Results: Mean age of children in the study was 2.79 ±1.01 years. There were
45 (70.3%) males and 19 (29.7%) females. Group A, had significantly better im-
provement in speech as compared to group B (p =0.000). regarding breast
feeding, both procedures showed almost similar improvement (p =0.224).
Conclusion: Frenulectomy was superior to frenulotomy as far as post operative
speech is concerned; however, both procedures were almost equally effective in
improving feeding problems (breast feeding) in babies with tongue ties.
Key Words: Ankyloglossia, frenulum, frenulotomy, frenulectomy, Z-plasty

This article may be cited as: Khan MA, Akram S, Usman HB, Ali G. Comparison of frenulotomy versus frenulec-
tomy in cases of ankyloglossia. J Postgrad Med Inst 2018; 32(2): 198-200.

is asymptomatic. Most of the children present at 1 to 3

INTRODUCTION
Ankyloglossia or tongue tie is a condition in which
the tip of the tongue cannot be protruded beyond the
lower incisor teeth because of short frenulum¹. Typical-
ly, the lingual frenulum separates before birth, allowing
the tongue to move freely. With tongue-tie, the lin-
gual frenulum remains attached to the ventral surface
of tongue. Its cause is unknown, although some cases
of tongue-tie have been associated with certain genet-
ic factors². Tongue-tie is more common in boys than
girls. Breast feeding difficulties have been reported as
the earliest complications associated with tongue tie³.
Restriction of tongue movement in an infant may pre-
vent the infant from taking enough breast tissue into
the mouth/difficulty in latching onto the nipples and
hence result in breast feeding problems such as painful
nipples and poor milk supply for the mother, leading
to frequent feeding and poor weight gain for the baby
despite frequent feeding. Other problems associat-
ed with tongue tie include difficulties with articulation
of sounds, dental problems and inability to lick an ice
cream or play wind instruments later in life. The sounds
which are affected and difficult to pronounce because
of tongue tie are “t, d, n”⁴. However, in many children it
years of life. The prevalence of ankyloglossia is around
3-4% varying from 0.02-10.7%3-6.
In ancient times, tongue tie has been reported to
be released with finger nails of mid-wives7. Nowadays,
there are different modalities for treating tongue tie in-
cluding simple release i.e. frenulotomy and frenulecto-
my (Z-plasty, V-Y plasty), release with electrocautery or
lasers8-10. We have carried out this research to find the
best method of treating ankyloglossia. This will help the
treating physicians to manage such cases in best opti-
mum way and to choose wisely the modality which has
better outcome for the patients.
METHODOLOGY
The study was carried out in CMH, Bahawalpur from
August 2014 to February 2016. It was a randomized
controlled trial. Sample size was calculated using online
Raosoft Sample Size Calculator. Prevalence was taken as
4% from the study of Segal et al⁶. Confidence interval
was taken at 95% and margin of error as 5%. Sample
size came out to be 59. To account for non-response
and design effect, sample size was increased to 64. The
sample of 64 cases was divided randomly in two groups

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 COMPARISON OF FRENULOTOMY VERSUS FRENULECTOMY IN CASES OF ANKYLOGLOSSIA

of 32 patients in each group (Group A and Group B)
using random number tables. Non-probability conve-
nient sampling technique was used. In Group A, pa-
tients underwent frenulectomy by Z-plasty and Group
B patients had frenulotomy (simple release) by bipolar
electrocautery. All those children with short frenulum
which caused restriction of tongue movements were
included in this study. Children with liver and renal dis-
eases; those with any bleeding disorders and tongue tie
along with other congenital anomalies i.e. cleft palate
were excluded from the study.
All patients were selected from outpatient depart-
ment of CMH, Bahawalpur. The main parental concerns
of bringing the babies to outpatient department were
noted along with their age and gender. Classic Z-plas-
ty was carried out in Group A, dividing the frenulum
with scissors and stitching the upper and lower bands
with vicryl. In Z-plasty, a releasing incision was made
on superior border and other on the inferior border of
lingual frenulum. Two flaps were raised, interchanged
and stitched to increase the length of frenulum. Bipolar
electrocautery was used in Group B, to cut the frenulum
and hemostasis was achieved automatically by cauteri-
zation. Both the groups were compared postoperatively
for functional assessment. Functional assessment was
carried out through effect on phonation and breast
feeding as described by parents. Functional assessment
was carried out at first postoperative week using Hazel-
baker Assessment Tool11. Effect on breast feeding was
assessed according to improvement in breast feeding,
less frequent feeds, decrease in pain and soreness of
nipples. Effect on phonation was categorized into mild
improvement, moderate improvement and best result/
improvement. Similarly effect on breast feeding was
categorized into mild improvement, moderate improve-
ment and best result/improvement.
Data had been analyzed using statistical package for
social sciences (SPSS) version 19. Frequency and per-
centage were calculated for qualitative variables while
mean and standard deviation (SD) were calculated for
quantitative variables. Chi square test was used to com-
pare qualitative variables between the two groups. A p
value < 0.05 was considered significant.
RESULTS
There were 64 cases of tongue tie in the present
study. The main concerns of parents for bringing their
children were difficulty in articulation (speech prob-
lems) and feeding difficulty, as shown in Table 1.
The age range of children was from 1 to 5 years with
mean age of 2.79 ±1.01 years. There were 45 (70.3%)
males and 19 (29.7%) females. In Group A, 23 showed
maximum improvement of speech. However, in Group
B, only 04 showed maximum improvements after sur-
gery, as shown in Table 2. As far as effect on breast feed-
ing was concerned, both procedures showed almost
similar improvement, as shown in Table 3.

Table 1: Main parental concerns in children with tongue tie

S. No. Main Complaints of Parents Frequency
1 Speech Problems 64 (100%)
2 Speech & Feeding Difficulty 25 (39.06%)

Table 2. Postoperative improvement in speech

Improvement Frenulectomy Frenulotomy
P value
in Speech (Z-Plasty Technique) (Release)
Mild 0 6
Moderate 9 22
0.000
Maximum/Best 23 4
Total 32 32

Table 3. Postoperative improvement in breast feeding

Improvement in Frenulectomy Frenulotomy
P value
Breast Feeding (Z-Plasty Technique) (Release)
Mild 0 2
Moderate 5 9
0.224
Maximum/Best 6 3
Total 11 14

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 COMPARISON OF FRENULOTOMY VERSUS FRENULECTOMY IN CASES OF ANKYLOGLOSSIA
. DISCUSSION
Majority of the parents in this study were aware of
the subject of tongue tie. The major adverse effects of
tongue tie as perceived by mothers included speech
difficulties. Breast feeding difficulties which have been
reported in literature as the earliest problem associated
with the tongue-tie, was not seen as the main concern
of parents in the subject study. Breast feeding problems
were expressed/narrated by very few mothers as shown
above. It may be possible that even if breast feeding
problems exist, mothers do not link them with tongue
ties because breast feeding is a key child care practice in
our society, reporting difficulties may be a reflection of
failure on the mothers’ part12. Secondly, many children
were old enough and had grown out of breast feeding
age so main complaint of respondents was articulation
difficulty. Because of social factors, usually, mothers
do not express the feeding problems in the outpatient
departments, especially to the male doctors. Further-
more, obvious disabilities like speech difficulties may
be more readily identified by mothers. However, it is a
well-known fact that most babies with ankyloglossia are
asymptomatic.
We have compared two common surgical meth-
ods of treating ankyloglossia i.e. frenulotomy ver-
sus frenulectomy. Frenulotomy by bipolar diathermy
is a quick, safe and conservative procedure; however,
frenulectomy (Z-plasty) is a more complicated, sophis-
ticated, time requiring surgical procedure. Z-plasty has
an advantage of increasing length of the scar which has
a direct positive effect on postoperative tongue mobili-
ty. In our study, we found Z-plasty a superior method to
simple release, as assessed by post operative functional
outcome i.e. effect on speech. Our results are in accor-
dance with the work of Yousefi et al13. However as far
as effect on breast feeding is concerned, there was no
significant difference between the two groups; similar
to that seen in Yousefi et al13. Almost similar effect of
both surgical techniques on breast feeding improve-
ment might be because of less number of cases i.e. 25
who were in breast feeding age. Heller et al14 also have
shown Z-plasty to be a superior procedure.
CONCLUSION
Frenulectomy (Z-plasty) was superior to frenulotomy
(release of tongue tie) as far as post operative speech
was concerned; however, frenulotomy and frenulecto-
my were almost equally effective in improving feeding
problems (breast feeding) in babies with tongue ties.
REFERENCES
1. Tongue-tie (ankyloglossia). American Academy of Oto-
laryngology-Head and Neck Surgery. Available at: http://
www.entnet.org/content/tongue-tie-ankyloglossia.
JPMI VOL. 32 NO. 2
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2. Tongue-tie. NHS Choices. Available at: http://www.
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3. Messner AH, Lalakea ML, Aby J, Macmohan J, Bair
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CONTRIBUTORS
MAK conceived the idea, planned the study, and
drafted the manuscript. SA and GA helped in ac-
quisition and interpretation of data and did litera-
ture search. HBU helped in manuscript writing. All
authors contributed significantly to the submitted
manuscript.
200